Is There a Chronic Pain Personality Profile?

Personality traits may be described as enduring patterns of perceiving, relating to, and thinking about the environment and oneself that may be exhibited in a wide range of social and personal contexts. When these traits are inflexible, maladaptive, and lead to significant functional impairment or subjective distress, they constitute personality disorders.1 Personality disorders are defined as qualitatively distinct clinical syndromes, and previous diagnostic manuals of the American Psychiatric Association (APA), such as the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), only used a categorical perspective in diagnosis. For example, the DSM-IV categorized personality disorders as paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, or obsessive-compulsive. In the APA’s new DSM-5,2 personality disorders represent maladaptive variants of personality traits that merge subtly into normality and into one another and are approved as an alternative, trait-specific, dimensional model. Thus, personality disorders are included in Section II, which features the same criteria found in DSM-IV, and Section III, which offers a research model.2

The essential feature of a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.2 This article provides an update to assessing and diagnosing these disorders, including an overview of such personality types among the chronic pain population.

Personality Disorder Prevalence

Research suggests that between 9.1% and 15% of adults in the United States have at least one personality disorder,3,4 and individuals frequently present with co-occurring personality disorders from different clusters. The three personality disorder clusters, all based on descriptive similarities, include:

See Table I for further detail. It should be noted that this old clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.2

The Pain Subpopulation

In the chronic pain population, the rate of personality disorders ranges between 30% and 60%.5-9 One study reported that 51% of patients with chronic pain met criteria for one personality disorder, and 30% met criteria for more than one.7 Another study found that 60% of persons with chronic pain met diagnostic criteria for a personality disorder, in contrast to research findings that 21% of patients with acute low back pain met diagnostic criteria.10

Typically, personality disorders are considered to predate the onset of injury and may complicate the course of a pain syndrome.11 Researchers have further noted that a significant number of persons with chronic pain syndromes specifically meet criteria for the Cluster C (anxious-fearful) personality disorders (eg, dependent with 10.6% prevalence and obsessive-
compulsive with 24.5% prevalence).6,11,12 There is also evidence to suggest there are high levels of prevalence of Cluster B (dramatic-emotional) personality disorders in the chronic pain population.9 The range of borderline personality disorder specifically in the chronic pain population ranges between 9.4% to 58%, with an average of about 30%.1,8 See Table I for detailed rates.6

A History of the Pain Personality

Since the time of Aristotle, philosophers have noted the interaction between sensation and emotion.9 Patients with personality disorders have a tendency to overreact to stress, including disease, in the characteristic pattern of their personality disorder.6 Personality type characteristics are accentuated by the medical condition, in this case, chronic pain. Therefore, these characteristics present predictable behavioral management problems.6 Over the past few decades, several theories have been proposed about personality in the chronic pain population.13

The first theory, by Engel in 1959,13 took a psychodynamic perspective. He postulated that underlying emotional conflicts shape personality features that inhibit the expression of emotional pain in an appropriate way. The next theory grew out of a trait approach, which focused on the objective and scientifically sound measurement of stable personality traits.13 Researchers found that a large subgroup of pain patients with chronic pain typically scored the “conversion-v” pattern, that is, elevation of the first three scales (Scale 1: Hypochondriasis, Scale 2: Depression, and Scale 3: Hysteria), of the Minnesota Multiphasic Personality Inventory (MMPI-2).13

With the advent of the biopsychosocial approach in the 1980s, the diathesis-stress model dominated the field. The model accentuates the interplay between an individual’s biological predisposition and the impact of the environment, such as stressors as a result of physical damage, to explain different responses to chronic pain. 13 Cloninger’s temperament and character model is the latest theory to be proposed. 13

Cloninger’s model builds off of the diathesis-stress approach and further differentiates between temperament and character. Temperament is defined as the emotional core of personality and presumed to be moderately inherited, while character describes the cognitive core of personality and is presumed to be influenced by the environment. The Cloninger model views personality along a continuum rather than applying a categorical approach. This take reflects the proposed research model for personality disorder diagnosis and conceptualization presented in the DSM-5.2

In fact, research using Cloninger’s proposal has portrayed a common personality profile of chronic pain. Personality symptoms of Cluster A have been found to be related to low reward dependence; Cluster B to high novelty seeking; and Cluster C to high harm avoidance.5 For example, pain symptoms may function as an interpersonal means of eliciting caring responses from others in patients with borderline personality disorder.8 Overall, patients with chronic pain are characterized by prevailing harm avoidance and lower self-directedness.13,14

Hirano S, Sato T, Narita T, et al. Evaluating the state dependency of the Temperament and Character Inventory dimensions in patients with major depression: a methodological contribution. J Affect Disord. 2002;69(1-3):31-38.

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